Anxiety disorders include generalised anxiety disorder, which is characterised by continuous and excessive worrying for six months or more. Specific phobias are characterised by anxiety provoked by a feared object/situation, resulting in avoidance. Social phobia is anxiety provoked by social or performance situations, and agoraphobia is anxiety about situations where escape may be difficult or help might not be available. Panic disorder is often the most debilitating anxiety disorder, involving recurring panic attacks which are distinct periods where a person experiences sudden apprehension and fearfulness, where they may present to services with shortness of breath, palpitations, chest pain or choking.

What is the evidence for rates of anxiety disorders in people with schizophrenia?

Moderate quality evidence suggests the rate of any anxiety disorder in people with schizophrenia is high, at around 38% compared to around 18% in the general population. Around 29% of people presenting with a first-episode of psychosis and around 15% of people with mild subclinical symptoms of psychosis also experience anxiety.

Social anxiety disorder was reported in around 21% of patients with schizophrenia, social phobia in around 15% of patients, generalised anxiety disorder in around 11% of patients, panic disorder in around 10% of patients, specific phobias in around 8% of patients, and agoraphobia in around 5% of patients.

June 2020

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Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder characterised by inattention, hyperactivity, and impulsivity. The estimated prevalence of ADHD in children under 18 years in the general population is around 5%. ADHD can persist into adulthood with an estimated prevalence of 2.5% in the adult general population. This topic assesses the prevalence of ADHD in people with schizophrenia.

What is the evidence for rates of ADHD in people with schizophrenia?

Moderate quality evidence suggests the prevalence of ADHD in children with schizophrenia is between 17% and 57%, and in adults with schizophrenia, the prevalence of ADHD ranges between 10% and 47%.

June 2020

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Autism spectrum disorders are neurodevelopmental conditions characterised by problems in social interaction and communication, and restricted, repetitive behaviours. Symptoms usually appear before three years of age, but can appear later. Autism spectrum disorders are often associated intellectual disability, however average-IQ is frequent.

What is the evidence for comorbid autism spectrum disorders?

Moderate to high quality evidence finds a large effect of more autistic symptoms in people with schizophrenia compared to controls, and a large effect of fewer autistic symptoms in people with schizophrenia compared to people with an autistic spectrum disorder.

The prevalence of schizophrenia spectrum disorders in people with an autism spectrum disorder is around 9.5%. In people with autism and an IQ over 70, the prevalence rate is lower, around 6.4%. The rate of schizophrenia in people with autism is significantly is higher than in people without autism.

June 2020

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Depression is characterised by a depressed mood and/or a loss of interest or pleasure in activities. Symptoms of depression include changes in appetite, weight, sleep, and psychomotor activity, decreased energy, blunted affect, social withdrawal, difficulty concentrating or making decisions, feelings of worthlessness, hopelessness and guilt, and thoughts of suicide. As many symptoms are common to both depression and the negative syndrome of schizophrenia it can be difficult to identify a comorbid depressive illness in people with schizophrenia. Identifying and treating a comorbid depressive illness may increase the likelihood of recovery from psychosis and reduce the likelihood of psychotic relapse.

What is the evidence for comorbid depression?

Moderate to high quality evidence found the prevalence of a diagnosed depressive disorder in people with first-episode schizophrenia was around 26%. The prevalence was higher when using depression symptom scores (around 45%). The prevalence of depressive disorders in people at high risk for psychosis who were showing subclinical symptoms was around 41%.

October 2020

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Dissociative symptoms involve a disruption in the usually integrated functions of consciousness, memory, identity, or perception. These symptoms can be transient or ongoing ,and are often seen as a reaction to trauma. They include depersonalisation (feeling detached from oneself), amnesia, imaginative involvement, absorption (being absorbed in your own mental imagery), and fragmentation of identity.

What is the evidence for dissociative disorders in schizophrenia?

Moderate quality evidence finds a large increase in dissociative symptoms in people with schizophrenia compared to people without schizophrenia, but less dissociation than people with a dissociative disorder.

People with schizophrenia and a self-reported history of trauma reported the most dissociation. The most common symptoms of dissociation were absorption and imaginative involvement.

June 2020

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An intellectual disability is impaired intelligence that is measured by an IQ lower than 70. Intellectual disabilities usually present during the first eighteen years of life and may also be known as an intellectual handicap, developmental disability or learning disability. Down Syndrome and Fragile X Syndrome are common causes of intellectual disabilities. It has been suggested that there is an increased risk of psychotic disorders in people with an intellectual disability. Antipsychotic medication is most commonly used to treat people with schizophrenia and intellectual disability, however there is often concern about the detrimental effects of antipsychotics on learning and cognition, and the long-term physical side effects.

What is the evidence for intellectual disability?

Moderate to high quality evidence suggests the prevalence rate of schizophrenia in people with an intellectual disability is around 3.5%. The rate is slightly higher in females and higher in mild cases of intellectual disability than in moderate or severe cases.

Moderate quality evidence suggests people with schizophrenia and mild/borderline intellectual disability may have more negative symptoms of schizophrenia than people with schizophrenia and no intellectual disability

June 2020

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Obsessive-compulsive disorder (OCD) can co-occur in people with schizophrenia. It involves persistent and intrusive thoughts (obsessions) and repetitive actions (compulsions). The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) defines obsessions as recurrent and persistent thoughts, urges, or impulses that are experienced as intrusive and unwanted with associated anxiety or distress. The individual attempts to suppress these obsessions by performing compulsions; repetitive behaviours (e.g., hand washing, ordering, checking) or thoughts (e.g., praying, counting, repeating words). The obsessions or compulsions are time-consuming and can cause significant impairment in social, occupational, or other areas of functioning. Related disorders include hoarding disorder, excoriation disorder (skin-picking), body dysmorphic disorder (obsessive focus on a perceived flaw in appearance) and trichotillomania (hair-pulling).

What is the evidence for OCD in people with schizophrenia?

Moderate to high quality evidence suggests the prevalence of OCD in people with schizophrenia is around 13.6% and the prevalence of obsessive-compulsive symptoms is around 30.3%. Rates are higher in outpatients than in inpatients (17% vs. 11%), and in people with chronic schizophrenia than in people with first-episode psychosis (13% vs. 0.8%).

People with schizophrenia and obsessive-compulsive symptoms, but not a diagnosis of OCD, have more severe symptoms of schizophrenia than people with schizophrenia without obsessive-compulsive symptoms.

Moderate to high quality evidence found no differences in cognition between those with OCD and those without OCD.

March 2022

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Personality disorders are enduring patterns of behaviours, thoughts and feelings that deviate from social norms. Many people exhibit these behaviours, thoughts or feelings occasionally, but deviations that persist across situations and cause significant distress and impairment are considered disorders.

There are a number of different personality disorders. These include; antisocial personality disorder (disregard for the rights of others); schizoid personality disorder (detachment of social interactions and limited emotional expression); schizotypal personality disorder (discomfort of close relationships, cognitive distortions and eccentric behaviour); paranoid personality disorder (distrust and suspiciousness of others); borderline personality disorder (self-harming, difficulty relating to others); histrionic personality disorder (patterns of attention-seeking behaviour and emotions); narcissistic personality disorder (disregard of others, inflated self-image); avoidant personality disorder (feelings of inadequacy, social inhibition); dependent personality disorder (extreme psychological dependence on others); obsessive-compulsive personality disorder (excessive control, orderliness); and personality disorder not otherwise specified (mixed symptoms).

What is the evidence for comorbid personality disorders?

Moderate quality evidence suggests the prevalence rate of personality disorders in people with schizophrenia or in those at high risk of psychosis is around 39.5%, with rates varying greatly across studies. This variation may be explained by the country in which the study was conducted, the study type, instruments of personality disorder diagnosis, or the type of patient care.

June 2020

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Polydipsia is the intake of more than three litres of fluid per day that cannot be better explained by a physical medical condition, but may be due to stress or a compulsive disorder. Polydipsia occurs more frequently in people with a mental illness than in the general population, and has been estimated to occur at rates of between 9-17% in psychiatric inpatients. Polydipsia may be measured through fluid intake, urine or plasma analysis. Severe polydipsia may lead to insufficient sodium in the body, which may cause coma or even death. As such, it is important to understand prevalence rates and potential treatments for polydipsia in people with schizophrenia.

What is the evidence for comorbid polydipsia?

Moderate to low quality evidence suggests people with schizophrenia have increased rates of polydipsia. Low quality evidence is unable to determine the pharmacological effects of demeclocycline or naloxone for psychosis-related polydipsia.

June 2020

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The Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) criteria for a diagnosis of post-traumatic stress disorder (PTSD) includes having been exposed to a trauma via direct means (e.g. threats, experience, or witnessing), or indirect means (e.g. learning that a relative or close friend has been exposed to a trauma).

For a diagnosis of PTSD, symptoms must last for more than one month and create distress and functioning impairment such as an inability to work, go to school, or socialise. Symptoms include persistently re-experiencing the traumatic event via intrusive thoughts, nightmares, or flashbacks. These can be brought on with exposure to traumatic reminders and are associated with emotional distress. As a result, avoidance of trauma-related stimuli occurs. There is often an inability to recall key features of the trauma. Other symptoms include negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities, feelings of isolation, irritability or aggression, risky or destructive behavior, hypervigilance, heightened startle reaction, and difficulty concentrating and sleeping.

What is the evidence for PTSD in people with schizophrenia?

Moderate quality evidence suggests the prevalence rate of PTSD in people with schizophrenia is around 12.3%. Following a first-episode of psychosis (up to 2.5 years), approximately 42% of patients experience PTSD symptoms and 30% are diagnosed with PTSD. Prevalence may be highest in patients with affective psychosis and in inpatient groups. Depression and anxiety may increase the risk of PTSD following a first episode of psychosis.

June 2020

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